Farrelly Simone, Lester Helen
Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, UK.
Health Soc Care Community. 2014 Sep;22(5):449-60. doi: 10.1111/hsc.12090. Epub 2014 Jan 16.
Individuals with schizophrenia and other psychotic disorders remain among the most marginalised in our communities. There has been increasing criticism of the current state of clinical treatment of such individuals as technological developments in medication provide little, if any, improvement in the lived experiences of mental health service users (SUs). In this context, there is a call for a re-orientation away from medication in the treatment of 'common factors' such as the therapeutic relationship (TR). The TR is well researched in psychotherapy settings; however, the components of beneficial TRs in the treatment of individuals with psychotic disorders are poorly understood. A critical interpretive synthesis was conducted to determine the current understanding of the TRs between individuals with psychotic disorders and their clinicians in community case management settings. A search of MEDLINE, PsycINFO, EMBASE and Social Policy and Practice Databases and grey literature between 1990 and 2011 identified 13 papers to be included in the synthesis. Three key components of beneficial TRs were identified: mutual trust, demonstration of mutual respect and shared decision-making. However, the synthesis revealed that such interactions are difficult to achieve in routine practice. The main barrier identified was a lack of clarity regarding the goal of interactions, which in turn created stakeholders with poorly defined roles and possibly oppositional needs. In this context of ambiguity, clinicians appear to de-emphasise interactions characteristic of beneficial TRs, and prioritise interactions that protect the SU and themselves in the case of a relapse. Structural symbolic interactionism is used to interpret these findings. For interactions characteristic of TRs to be prioritised in the treatment of individuals with psychotic disorders, a clearer evidence base for the importance of the TR and a clear statement of purpose of treatment are required.
精神分裂症和其他精神障碍患者在我们的社区中仍然是最边缘化的群体之一。随着药物治疗技术的发展对心理健康服务使用者（SU）的实际生活体验几乎没有改善（如果有改善的话），人们对这类患者当前的临床治疗状况的批评越来越多。在这种背景下，有人呼吁在治疗诸如治疗关系（TR）等“共同因素”时，应从药物治疗转向其他方向。TR在心理治疗环境中已有充分研究；然而，对于精神障碍患者治疗中有益的TR的组成部分却知之甚少。本研究进行了一项批判性解释性综合分析，以确定在社区病例管理环境中，精神障碍患者与其临床医生之间TR的当前理解情况。通过检索1990年至2011年期间的MEDLINE、PsycINFO、EMBASE以及社会政策与实践数据库和灰色文献，确定了13篇论文纳入综合分析。确定了有益TR的三个关键组成部分：相互信任、相互尊重的表现和共同决策。然而，综合分析表明，这种互动在常规实践中难以实现。确定的主要障碍是互动目标不明确，这反过来又导致利益相关者的角色定义不清，需求可能相互对立。在这种模糊的背景下，临床医生似乎不再强调有益TR的互动特征，而是优先考虑在复发情况下保护SU和他们自己的互动。运用结构符号互动主义来解释这些发现。为了在精神障碍患者的治疗中优先考虑TR的互动特征，需要一个更清晰的关于TR重要性的证据基础以及明确的治疗目的陈述。
